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Republic of KenyaMinistry of HealthAn Implementation FrameworkforHOME- ANDCOMMUNITY-BASED CAREIN KENYA

THIS PUBLICATION is one of a series of materials that reflect theGovernment of Kenya's concern for and commitment to the fight againstthe HIV/AIDS epidemic. Books in the series are:- National Strategy to Strengthen Home-Based Care Access, Sustainability andQuality in Kenya 2005–2009- National Home-Based Care Policy Guidelines- National Home-Based Care Programme and Service Guidelines- Training Home-Based Caregivers to Care for People Living with HIV/AIDS atHome – A Curriculum for Training Community Health Workers- Home Care Handbook- Home-Based Care Orientation Module for Health Service Personnel andProgramme Managers- National Voluntary Counselling and Testing Guidelines- Training Curriculum for Voluntary Counselling and Testing- National Guidelines on Prevention of Mother to Child Transmission of HIV- National Policy Guidelines on the Use of Anti-Retrovirals- National Condom Policy and Strategy 2001–2002- An Implementation Framework for Home- and Community-Based Care inKenya

Republic of KenyaHOME- AND COMMUNITY-BASED CARE FOR PEOPLELIVING WITH HIV/AIDSAn Implementation FrameworkforHOME- AND COMMUNITY-BASEDCARE IN KENYANational AIDS/STD Control ProgrammeMinistry of HealthPO Box 19361 - City Square • Nairobi 00200, KenyaTel: 254-20-272-9502/9549 • Fax: 254-20-271-0518www.aidskenya.orgJanuary 2008i

ANY PART OF THIS DOCUMENT may be freely reviewed, quoted, reproduced ortranslated in full or in part, provided the source is acknowledged. It may not be sold orused in conjunction with commercial purposes or for profit.An Implementation Framework for Home- and Community-Based Care in KenyaPublished by:National AIDS/STD Control ProgrammePO Box 19361Nairobi, KenyaEdited anddesigned by:Margaret Crouch© 2008, National AIDS/STD Control ProgrammeiiHOME- AND COMMUNITY-BASED CARE IMPLEMENTATION FRAMEWORK

ContentsList of Abbreviations and Acronyms vForewordviiAcknowledgementsviiiExecutive Summaryix1. Introduction 11.1 Definition and Vision of HCBC 11.2 Purpose and Rationale of theHCBC Framework 21.3 Guiding Principles and CoreValues of the HCBC Framework 32. Comprehensive Care Package 42.1 Elements of ComprehensiveCare 42.1.1 Clinical Care 42.1.2 Basic Nursing Care 52.1.3 Palliative Care, Pain Reliefand Symptom Management 52.1.4 Psychosocial Support 52.1.5 Counselling 52.1.6 Spiritual Support andGuidance 62.1.7 Confidentiality 62.1.8 Life Skills Development 62.1.9 Family Care and Support 62.1.10 Food and Nutrition 72.1.11 Prevention of HIVTransmission 82.1.12 Linkage, Coordination,Referral and Networking inHCBC 82.2 Monitoring and Evaluation ofComprehensive Care Services 92.2.1 Documentation 92.2.2 Quality of Services 102.2.3 Supportive Supervision 102.3 Operations Research 103. Minimum Package of Care 113.1 Elements of the HCBC MinimumPackage 113.1.1 Nursing Care and PalliativeCare 113.1.2 Clinical Care with anEmphasis on Treatment Literacyand Sustainability 113.1.3 Family Care and Support 123.1.4 Capacity Building 123.1.5 Establishing Linkage,Referral and NetworkingSystems 123.2 Monitoring and Evaluation of theMinimum HCBC Package 124. HCBC ImplementationStrategies 134.1 Systems Strengthening 134.1.1 National Level Actions 134.1.2 Provincial Level Actions 144.1.3 District and Divisional LevelActions 144.1.4 Community and FamilyLevel Actions 144.2 Capacity Building 144.2.1 Standardizing the TrainingCurriculum and Length/Durationof Training 144.2.2 Identifying/AppointingQualified Trainers/Facilitators 15Contentsiii

4.2.3 Harmonizing TrainingVenues and Monitoring ofTrainings 154.2.4 Formalizing Certificationof Trainees 154.3 Financing and EnsuringSustainability 154.3.1 Preparing AnnualOperational Plans 164.3.2 Promoting Public–PrivateSector Partnerships (PPP) 164.3.3 Pooling Resources 164.3.4 Mobilizing CommunityResources 164.4 Encouraging Volunteerism 164.5 Linkages, Referral System andNetworking 174.5.1 Integrating Services 174.5.2 Strengthening Linkagesand Networking 174.5.3 Establishing ReferralSystems 174.5.4 Handling Logistics andSupplies 184.5.5 Ensuring Food Security,Supplements and Food forPrescription 184.6 Quality Assurance and QualityControl 184.7 Supervision and Coordination 184.7.1 Supportive Supervision 184.7.2 Coordination 184.7.3 HCBC Organogram 195. National HCBC ImplementationSteps 205.1 Assessment 205.1.1 Situation Analysis 205.1.2 Logistic Analysis 205.1.3 Networking, Referral andLinkage 205.2 Planning and Organizing 215.3 Implementation 215.4 Monitoring and Evaluation 216 Monitoring and Evaluation 226.1 Importance of M&E 226.2 Link between MOH and NACCM&E System 226.3 Tools 23AnnexesA: Contributing StakeholderOrganizations 24B: Additional Reading 25C: Standard Minimum HCBC KitContent (Revised 2006) 27ivHOME- AND COMMUNITY-BASED CARE IMPLEMENTATION FRAMEWORK

Abbreviations and AcronymsACKAIDSAOPARTARVsCBDCBOCCCCHWCHEWCORPCSODASCODFIDDHBCCDHPDHMTDMOHDOTSFHIHBCHCBCAnglican Church of KenyaAcquired immunedeficiencysyndromeAnnual operational planAnti-retroviral therapyAnti-retroviral drugsCommunity-baseddistributor / distributionCommunity-basedorganizationComprehensive care clinicCommunity health workerCommunity healthextension workerCommunity-ownedresource personCivil society organizationDistrict AIDS/STD ControlCoordinatorDepartment forInternational DevelopmentDistrict Home-Based CareCoordinatorDivision of HealthPromotionDistrict HealthManagement TeamDistrict Medical Officer ofHealthDirectly observed therapyshort courseFamily Health InternationalHome-based careHome- and communitybasedcareHIV Human immuno-deficiencyvirusJHPIEGO Johns Hopkins Programfor International Educationin Gynaecology andObstetricsKANCO Kenya AIDS NGOsConsortiumKENWA Kenya Women with AIDSKMTC Kenya Medical TrainingCollegeKNH Kenyatta National HospitalKRCS Kenya Red Cross SocietyM&E Monitoring and evaluationMIPA Meaningful involvement ofpeople with AIDSMOH Ministry of HealthNACC National AIDS ControlCouncilNASCOP National AIDS/STD ControlProgrammeNEPHAK Network of People withHIV/AIDS in KenyaNGO Non-governmentorganizationOI Opportunistic infectionOVC Orphans and vulnerablechildrenPHMT Provincial HealthManagement TeamPITC Provider initiated testingand counsellingPLHA Person/people living withHIV/AIDSAbbreviations and Acronymsv

PMTCTSTITBVCTPrevention of mother tochild transmission (of HIV)Sexually transmittedinfectionTuberculosisVoluntary counselling andtestingWEHMISWHOWOFAKWEM Integrated HealthServicesWorld Health OrganizationWomen Fighting AIDS inKenyaviHOME- AND COMMUNITY-BASED CARE IMPLEMENTATION FRAMEWORK

ForewordThe preparation of this HomeandCommunity-Based CareImplementation Frameworkhas come at a time when theMinistry of Health is shifting its focusthrough the Community Strategytowards strengthening health careprovision at level 1 (the community –villages, households, families,individuals). HCBC is an integral partof the Ministry’s Community Strategy.Care for people living with HIV/AIDSis continually evolving as healthservice providers respond to thechanging needs of clients, familiesand communities.More bedridden patients are alsorecovering and graduating fromdebility to mobility, thereby becomingactive members of their community onlife-long anti-retroviral treatment. Thiscalls for the extension of comprehensivecare beyond the health facility tothe home and community level. Theframework presented here reflectsthat critical change of focus fromhome-based care to home- andcommunity-based care.The HCBC framework is a guideto implementers, supervisors anddonor agencies. The goal is to ensurethe provision of quality care for theHIV infected and other chronically illpeople at the home and communitylevel. International and local donoragencies as well as HCBCimplementing partners will be requiredto use this framework for theimplementation of HCBC activities inline with the relevant priority areas oftheir respective districts. Governmentofficials at the various levels will alsouse the framework to monitor, guideand supervise the implementation ofHCBC programmes. With arecommended minimum package forHCBC, rolled out according to anationally recommended HCBCimplementation model, the Ministryexpects that standards and quality ofcare will be upheld.Through the use of this HCBCguiding framework, implementingpartners will reflect the Government’scommitment to ensure that those withdebilitating illnesses and thoseinfected and affected by HIV receivea sustainable continuum of care ofthe highest quality in their homes andin their communities.Dr. Francis KimaniDirector of Medical ServicesMinistry of HealthForewordvii

AcknowledgementsNASCOP – National AIDS/STDControl Programme of theMinistry of Health – wishes toacknowledge the efforts putinto the preparation of this HCBCimplementation framework by variousstakeholders. Among others, theseinclude the National AIDS ControlCouncil (NACC) and the Ministry ofHealth’s Department of Sector Planningand Management, and the divisions ofNursing, Health Promotion and ClinicalMedicine. Ministry of Health representativesfrom Nyanza, Coast and NorthRift Valley provinces, Kisumu town, andSiaya, Nakuru and Mwingi districts alsomade significant contributions.Other stakeholders includePathfinder International, St. JohnAmbulance, Family Health International(FHI), Johns Hopkins Program forInternational Education in Gynaecologyand Obstetrics (JHPIEGO), WomenFighting AIDS in Kenya (WOFAK),Network of People with HIV/AIDS inKenya (NEPHAK), Kenya Women withAIDS (KENWA), Kenya Medical TrainingCollege (KMTC), Mildmay International,Kenyatta National Hospital VCT Centre,Kenya Red Cross Society, Kenya AIDSNGOs Consortium (KANCO), Catholicdioceses of Kitui and Nakuru homebased-care projects, Maua MethodistChurch palliative and community-basedcare project, ACK Diocese of EldoretHIV care project, Karatina home-basedcare project, Health Policy Initiative,WEH Integrated Health Services(WEHMIS), the World HealthOrganization (WHO), and UnitedNations Children’s Fund (UNICEF).Special thanks go to the task teammembers, coordinated by NASCOP’sPauline Mwololo, who worked longhours to complete this framework. Theteam members were Eva Mwai of St.John Ambulance; Mable Wendo andCharles Omondi – MildmayInternational; Lenet Bundi – NASCOP;Anne Kanyuga and Isabella Ndwiga –Division of Health Promotion; ChristineOtieno – Kenyatta National Hospital;Jane Otai –JHPIEGO; Jane Harriet –FHI; Juliana Misore – KMTC Kisumu;Grace Ongwae – KMTC Nairobi; andRosemary Okeyo – Constella Futures.Finally, our gratitude goes to theDepartment for InternationalDevelopment (DFID) through ConstellaFutures for their continued financial andtechnical support throughout the entireframework preparation process.To all of you go special thanks foryour tireless contributions to thisendeavour.Dr. Ibrahim MohamedHead, National AIDS/STD ControlProgramme (NASCOP)Ministry of HealthKenyaviiiHOME- AND COMMUNITY-BASED CARE IMPLEMENTATION FRAMEWORK

Executive SummaryThis document describes asystematic framework forestablishing and maintaininghome- and community-basedcare (HCBC) in Kenya. Theframework is intended to guidegovernments, national andinternational donor agencies, and civilsociety organizations in developing orexpanding HCBC programmes.Approaches to HCBC are continuallyevolving in response to the changingneeds of patients/clients and theirfamilies. In the beginning, most homebasedcare programmes focused onthe care of the sick and family- The Home-Based Care Logo -The separate elements of the emblemare familiar, but are combined in asignificant way.The red ribbon represents AIDS.And the family is just that – a family,the foundation of our communities, butwith the red AIDS ribbon superimposedto indicate that HIV/AIDS is not anaffliction of individuals only, it affectseveryone. The heart is widelyrecognized as a symbol of love andcaring. The green is also significant.Green is regarded by many as thecolour of hope. Thus the emblemportrays an AIDS-affected familysurrounded by a heart full of hope,caring and community support. That isthe message of home-based care.Executive Summarycaregivers. As the AIDS epidemiccontinued to grow, orphan carebecame a critical concern. And nowwith the availability of highly effectiveanti-retroviral drugs (ARVs), more andmore people are graduating frombeing bedridden to being activemembers of the community on lifelongARV treatment and in need ofcomprehensive care.This poses a major paradigm shiftfrom home-based care (HBC) – thecare of a single sickly family memberat home – to home- and communitybasedcare (HCBC), which is a broadbasedapproach rooted in acommunity’s concern for friends andneighbours in need. The framework isan integral part of the communitystrategy for strengthening health careat level 1 of the Kenya EssentialPackage for Health (KEPH)developed by the Ministry of Health.This document describes theelements of a comprehensive HIV/AIDS care package, the minimumcare package, the national model forHCBC implementation and actions forstrengthening the systems thatsupport the model.Comprehensive Care PackagePeople with HIV and other chronicand terminal illnesses have multipleneeds that can only be addressedthrough comprehensive care. Suchix

care is continuous from the healthfacility to the home and communitylevel, and is not simply restricted totreatment. The key elements ofcomprehensive care include clinicalcare, nursing care and palliative care.Other aspects are psycho-socialsupport, counselling and HIV testing,and spiritual support. Underliningthese are family care and support oforphans and vulnerable children(OVC), and care of the caregivers.Finally, food and nutrition support andeducation, as well as programmemonitoring and evaluation, are criticalcomponents.Minimum Care PackageTo ensure that the patient and familyreceive quality care regardless oforganizational constraints, a minimumcare package has been identified thatincludes: nursing and palliative care,clinical care that emphasizestreatment literacy and sustainability ofcare, family care and OVC support,capacity building, and monitoring andevaluation. To ensure that all theelements of the minimum carepackage are addressed, a strongreferral and networking system linkingthe patient and family to otherservices is required.Strengthening Support SystemsStrong systems will strengthen andsupport the implementation of theminimum package for HCBC andtherefore maintain the provision of ahigh quality continuum of care.Personnel, administration and qualitycontrol are among the essentialsystems. For example, it is necessaryto maintain an optimal number andquality of staff, strengthen administrationand supervision, and provideconsistent monitoring and evaluation.Other systems are quality assuranceand accreditation, leadership, coordination,integration of services,logistics and supplies. Referral,linkages and networking at all administrativeand health care levels areother essential contributors to thesystem.Target AudienceThis framework targets three levels ofaudiences:• Policy makers and senioradministrators, middle managers,and those who develop and runHCBC programmes.• Government officials at thevarious levels who will need theframework to monitor, guide andsupervise the implementation ofHCBC programmes.• Civil society implementingpartners, who will be required touse this framework for theimplementation of HCBC activitiesin line with the relevant district’spriority areas.With this framework for a recommendedminimum package for HCBCand a nationally recommended HCBCimplementation model, it is anticipatedthat standards and quality of care willbe maintained and the quality of lifeof all those affected will be improved.All partners implementing HCBCprogrammes should adhere to thestandards and criteria stipulated ineither the comprehensive or theminimum health care packages.xHOME- AND COMMUNITY-BASED CARE IMPLEMENTATION FRAMEWORK

1 IntroductionServices for the care ofKenya’s sick at home and inthe community arenumerous, but are oftenestablished without full awareness ofwhat is expected of them at aminimum. Despite the existence ofthe Programme and Service Guide forHome-Based Care, different modelsof care have been implementedwithout adherence to an agreed uponstandard. This ImplementationFramework for Home- andCommunity-Based Care (HCBC)intends to bridge that gap by settingout the minimum standards of care forHCBC programmes. The framework isa guide to implementers andsupervisors with a goal of ensuringthe provision of quality care for theHIV infected and other chronically illpeople at the home and communitylevel.Initiated by the Ministry of Health’sNational AIDS/STD ControlProgramme (NASCOP), theframework is the result of thecollaborative effort by a wide array oforganizations and agencies workingin or supporting HCBC programmesthat were committed to improving thequality of care under theseprogrammes. (Refer to Annex A for alist of the participating stakeholders.)International and local donoragencies, along with civil society,Facts about HIV and AIDSHome- and community-based careis an integrated, comprehensive,continuum of care for peopleinfected with HIV as well as otherdisabling or terminal diseases.faith-based and non-governmentorganizations (CSOs, FBOs, NGOs)will be required to use this frameworkfor the implementation of HCBCactivities in line with the relevantdistricts’ priority areas. Governmentofficials at the various levels will alsouse the framework to monitor, guideand supervise the implementation ofHCBC programmes. It is anticipatedthat the use of this recommendedminimum package for HCBC will raisethe standards of care and improve thequality of life for individuals, familiesand communities.1.1 Definition and Vision ofHCBCHome- and community-basedcare is an integrated,comprehensive, continuum ofcare for people infected with HIV aswell as those with chronic disabling orterminal diseases. The principles ofcare are the same whether one hasHIV or AIDS, stroke, cancer, diabetes,or hypertensive disease.1

The vision is to integrate HCBCinto other health services so as toprovide a holistic, sustainable, stigmafreeand high quality continuum ofcare that is accessible to all those inneed and supported by motivatedcommunity and health facility careproviders.1.2 Purpose and Rationale ofthe HCBC FrameworkComing at a time when theMinistry of Health is shifting itsfocus through the CommunityStrategy 1 by strengthening healthcare provision at level 1 (thecommunity – village/households/families/individuals), this frameworkaddresses HCBC as an integral partof the Community Strategy. HCBC iscontinually evolving as health serviceproviders respond to the changingneeds of clients, families andcommunities.For example, with the availabilityof highly effective anti-retroviral drugs(ARVs), more and more bedriddenpatients are recovering and regainingtheir health, thereby graduating fromdebility to mobility and returning toactive roles in the community. Withsuch patients being on life-long ARVtreatment and requiring comprehensivecare, the need to go beyond thehome to community level care iscritical. This is the root of the changeof focus from home-based care tohome- and community-based care.1Taking the Kenya Essential Package forHealth to the Community: A Strategy for theDelivery of LEVEL ONE SERVICES, publishedby the Ministry of Health, June 2006 (hereafterreferred to as the Community Strategy).-Community-based health careoccurs when community memberstake on the responsibility of initiatingand sustaining their own health care.It implies the use of locally availableresources and the community’s fullparticipation and involvement indecision making for the planning,organizing, implementing, monitoring,and evaluating of these services.According to the Kenya EssentialPackage for Health (KEPH), 2 thereare six levels of care at which HCBCwould be integrated for different careprovision activities. These are:• Level 1: Community: village/households/families/individuals• Level 2: Dispensaries/clinics• Level 3: Health centres,maternities, nursing homes• Level 4: Primary hospitals –District and sub-district hospitals• Level 5: Secondary hospitals –Provincial hospitals• Level 6: Tertiary hospitals –National hospitalsThe rationale for the HCBCimplementation framework is to guideprogramme implementers by definingthe minimum standards and a modelof care that best serves the needs ofclients, families and communities. Theminimum package and model of carewill be supported by strong systemsof capacity building, linkages,networking, M&E, coordination andsupervision.2Reversing the Trends: The Second NationalHealth Sector Strategic Plan of Kenya – TheKenya Essential Package for Health, publishedby the Ministry of Health, July 2007.2 HOME- AND COMMUNITY-BASED CARE IMPLEMENTATION FRAMEWORK

All partners implementing HCBCprogrammes should adhere to thestandards and criteria stipulated ineither the comprehensive or theminimum health care packages.1.3 Guiding Principles andCore Values of the HCBCFrameworkIn fulfilling the purpose of theHCBC Framework, partners willadhere to and promote thefollowing principles and core values:• Empowerment: Helping patients/clients to help themselves byproviding them with the skills andopportunities to develop theirpotential and continuouslyimprove.• Integrity: Treating others as wewant to be treated.understanding that quality of careis the responsibility of every careprovider.• Respect for the basic humanrights of PLWHAs: Using theHIV/AIDS Act of the Governmentof Kenya to uphold the rights of allthose who are infected andaffected by HIV. All implementersshould be familiar with this Act(Cap 14 of the laws of Kenya,2006).• Mainstreaming gender: Definingcomplementary gender roles andresponsibilities, promotingwomen’s empowerment,addressing traditional inequitablegender-related cultural practices,and addressing gender imbalancein home- and community-basedcare and service delivery.• Partnership: Workingtogether with patients/clients,collaborators and beneficiariesof HCBC to achieve moresustainable and efficientoutcomes.• Teamwork: Harnessingthe benefits of synergy toenhance performance andprovide learning anddevelopmentopportunities.• Quality care: Ensuringthat we fully understandand meet patient/clientneeds, with theIntroduction3

2 Comprehensive CarePackagePeople with HIV/AIDS andother chronic and terminalillnesses have multipleneeds that can beaddressed effectively only throughcomprehensive care. Such care iscontinuous – from the health facility tothe home and community level – andnot simply restricted to treatment. It isrecognized that not all HCBCproviders will be able to meet all theneeds of the infected and affected.Nevertheless, by understandingthe comprehensive care package,and through it generating a widercommunity response and participation,they will be able to implementthe minimum HCBC package and anyadditional elements for whichresources are available. (For a list ofadditional reading materials related toHCBC refer to Annex B.)2.1 Elements of ComprehensiveCareHere we are discussing theideal approach to HCBC – thefull range of care and referralservices needed for the delivery ofoptimum care at the community level.The continuum includes clinical andnursing care, pain relief, andcounselling and spiritual support,among others.2.1.1 Clinical CareClinical care focuses on diagnosisand treatment to meet the healthneeds of the patient/client. Actionhere includes:• Assessing the patients’/clients’needs through physicalexamination, observation andhistory taking.• Planning to meet identified needs.• Providing clinical servicesincluding drugs.• Developing treatment literacy andproviding adherence counselling.• Recognizing and acting on needsrequiring appropriate referrals.• Drawing up a discharge plan.• Following up on the implementationof the discharge plan and thewelfare of the patient/client.The comprehensive HCBCpackage includes:• Clinical and basic nursing care• Palliative care, pain relief• Psychosocial support andcounselling• Life skills development• Family care and support• Food and nutrition• Prevention of HIV transmission• Linkage, coordination, referral,networking4 HOME- AND COMMUNITY-BASED CARE IMPLEMENTATION FRAMEWORK

2.1.3 Palliative Care, Pain Relief andSymptom Management2.1.2 Basic Nursing CareBasic nursing care refers to the dayto-daymaintenance of a person’shealth. Nursing care includes theassessment of the client’s needs andproblems on the basis of therequirements of activities of dailyliving and the subsequent preparationof caregiver plans. These plans areimplemented, monitored andevaluated in accord with the identifiedneeds, including appropriate referrals.Nursing care also Includes care ofpressure areas for bedridden patientsand help with maintaining mobility,bathing, wound cleansing, skin careand oral hygiene. It covers adequateventilation in the home, as well asguidance and support for propernutrition. Prevention of infectionsthrough the use of antiseptics anddisinfectants along with the use ofprotective materials like gloves andencouraging the use of condoms arealso part of the basic nursing careprovided. Other activities includehand-washing, cleaning linen withsoap and water, homestead hygiene,and burning or safe disposal ofhuman and other waste materials.Palliative care is the combination ofactive and compassionate long-termtherapies intended to comfort andsupport individuals and families livingwith a chronic life-threatening illness.Pain relief is an essential element ofpalliative care. Symptom managementruns from interventions forreducing fever and relieving pain, totreating diarrhoea, vomiting andcough.2.1.4 Psychosocial SupportPsycho-social support is an integralpart of comprehensive care. Itresponds to the total well-being of theperson and the family affected by theillness, particularly HIV/AIDS, throughinterventions that focus on theemotional, mental and social aspects.These aspects will be addressedthrough counselling, spiritual supportand guidance, as well as issuesrelating to confidentiality as describedbelow.2.1.5 CounsellingCounselling is an essential element ofcare for the sick person, familymembers and care providers toenhance their capacity to cope withthe disease and provide care.Counselling, as a professional skill,can be provided through individual,family or group counsellingapproaches. Group counsellingaffords an opportunity for people withsimilar needs to share theirComprehensive Care Package5

experiences on how they havemanaged and coped with theircondition.The process must integratestructured counselling principles andshould engage people living with HIV/AIDS as key partners, makingreference to the MeaningfulInvolvement of People with AIDS(MIPA) guidelines. The outcome ofcounselling will be to promote positiveliving and prevention of further HIVtransmission and re-infection. Thismay be achieved through individual orgroup counselling. Key elements tobe incorporated include goodinterpersonal communication withrespect and dignity, a nonjudgementalattitude, empathy andcultural sensitivity, and respect forpositive traditional practices.2.1.6 Spiritual Support andGuidanceSpiritual support and guidance haveproven effective in providing hopeand consolation to the affectedindividual and family. This kind ofsupport should be sensitive todifferent beliefs, whether traditional orconventional faith. Spiritual leadersplay a vital role in this area and mayassist when and where possible.2.1.7 ConfidentialityConfidentiality is one of the manychallenges in HCBC, particularlybecause of the fear of stigmatizationand discrimination associated withHIV/AIDS. It is therefore paramountthat HCBC providers be sensitive tothe concerns of the individual and theKey elements of counsellingservices include goodinterpersonal communication,respect for personal dignity, anon-judgemental attitude,empathy and culturalsensitivity.family affected. The providers shouldencourage shared confidentiality,bearing in mind that the rights of thesick person or person living with HIV/AIDS are respected. The processmust enable the person and thehousehold to cope with the situationeffectively.2.1.8 Life Skills DevelopmentPeople living with HIV/AIDS should beencouraged to adopt positive lifestyles to strengthen skills that enablethem to effectively prevent furtherinfection. Involvement in communitygroups gives them a sense ofbelonging, hence promotesresponsible behaviour andsustainable positive lifestyles. Makingthem aware of relevant reproductivehealth services will help them accessdual protection against re-infectionand unplanned pregnancies.2.1.9 Family Care and SupportThis is a holistic approach toproviding care and support beyondthe sick individual. A person with achronic illness is a member of a familyunit, hence care and support shouldbe provided within the context of thefamily. Family care and support6 HOME- AND COMMUNITY-BASED CARE IMPLEMENTATION FRAMEWORK

should therefore take intoconsideration the inter-relationshipsamong family members and familyroles in providing the necessary careand support. Among others thisinvolves psycho-social and spiritualsupport, planning for the children’sfuture, bereavement counselling,mobilization of family support, and theuse of a memory book, which isencouraged where appropriate.Other important aspects toconsider under family care andsupport are care for orphans andvulnerable children (OVC) and carefor caregivers.OVC Care and SupportCare and support for OVC mustencompass children’s rights asstipulated in the Children Act (cap 586of 2001) and the Kenya National OVCPolicy Guidelines. Such supportincludes child health services,immunization, nutrition, education,legal protection and inheritance rights,and shelter. The HCBC providers,who are often the first to come incontact with OVC, need to link themwith the specific organizations orinstitutions that offer the necessaryservices as stipulated in the KenyaNational OVC Policy Guidelines.Children must be regarded as keyplayers and not just as beneficiariesof care and service delivery. Theyshould therefore be empowered toChildren are key players andnot just beneficiaries of careand service delivery, especiallyin matters related toinheritance.Comprehensive Care Packageparticipate actively in various care andsupport interventions, particularlythose related to issues of inheritance.Care for CaregiversCaring for caregivers and familymembers is important to avertburnout, a condition brought about byexcessive emotional stress andphysical strain. Caregivers should belinked to relevant support systemsthat address their needsappropriately. Friends, spiritualleaders, neighbours and communityvolunteers can provide support tohelp both the sick and the familycaregivers. Special attention shouldbe given to child and elderlycaregivers because of the enormouschallenges they face in offeringquality care. To ensure quality of careand support services, caregiversshould be supplied with appropriateinformation on self-care and givensupportive supervision and othercapacity building services.2.1.10 Food and NutritionProper food and nutrition areessential for improving the health ofthe sick and for maintaining the wellbeingof PLWHAs and those withother chronic illness. Providingnutrition support should involve short-,medium- and long-term interventions.Short-term interventions may come inthe form of food by prescription tomeet immediate urgent needs. In themedium term, interventions are morelikely to entail palatability issues andconsumption for the purpose ofrecuperation and recovery, while thelong-term services may involve7

ensuring food security forsustenance. Long-term interventionswill call for multi-disciplinaryapproaches that build communitycapacities for food production, safetyand security. The Kenya NationalFood and Nutrition Guidelines providedetails on food and nutrition.Maintenance of proper food hygienethrough the entire process ofpreparation, cooking, serving andstorage helps to prevent food-bornediseases.2.1.11 Prevention of HIVTransmissionPrevention of HIV transmission is animportant aspect of reducing newinfections. Services here includevoluntary counselling and testing(VCT), provider initiated testing andcounselling (PITC), and prevention ofmother to child transmission (PMTCT)of HIV. These are services throughwhich clients are supported to makeinformed decisions relating to testing,treatment and care. In addition,caregivers must maintain standards ofcare to avoid infection, hence theimportance of observing infectionprevention steps when providing care(see Section 2.1.2).Behaviour change promotesbehaviours that reduce the riskof either acquiring ortransmitting HIV infection. Thismay entail peer education, theparticipation of “expert patients”,condom promotion, reproductivehealth and HIV integration.Prevention with Positive InitiativeThe involvement of people living withHIV and AIDS through the MIPAprinciple is a key element for abatingstigma and promoting prevention andpositive living. MIPA should beencouraged at all levels. Behaviourchange promotes behaviours thatreduce the risk of either acquiring ortransmitting HIV infection. Actionshere may entail peer education andthe participation of “expert patients”.These are HIV-positive patients whoare living positively and are involvedin outreach to encourage others tolive positively, prevent HIVtransmission and adhere to treatment.Among other measures are condompromotion, reproductive health andHIV integration. In all ourinterventions, efforts must be made toaddress the issue of preventionamong discordant couples.Counselling and TestingCounselling and testing servicesprovide an entry point to the provisionof care and accurate information onHIV/AIDS. Such services areavailable in many communitiesthrough VCT centres, PITC, hometesting and counselling, PMTCT, anddiagnostic testing and counselling.2.1.12 Linkage, Coordination,Referral and Networking inHCBCThe purpose of strengthening linkage,coordination and referral is to ensurecontinuity of care. Roles andresponsibilities of service providers atall levels must be defined. It is alsonecessary to identify, map and8 HOME- AND COMMUNITY-BASED CARE IMPLEMENTATION FRAMEWORK

harmonize a database of servicesavailable in line with thecomprehensive care services. Theinformation available in the databasewill facilitate follow up and referral toservices at different levels. Throughthe supportive supervision structuresof the provincial and district healthmanagement teams (PHMT andDHMT, respectively), equitabledistribution of services and gaps inservice provision will be identified andaddressed.2.2 Monitoring and Evaluation ofComprehensive Care ServicesEssentially based on reportsfrom routine supervisory fieldvisits and periodic reviews,monitoring and evaluation in HCBC isan important aspect of quality controlin the implementation of HCBCactivities. Key considerations in M&ELong-term nutrition servicesmay involve ensuring foodsecurity for sustenance. Theycall for multi-disciplinaryapproaches that buildcommunity capacities for foodproduction, safety and security.are documentation, quality of caremonitoring, supportive supervisionand operations research.2.2.1 DocumentationData should be kept on activitiescarried out to deliver the componentsof comprehensive care services at alllevels of the care continuum. Thisallows feedback on such activitiesand will facilitate planning,implementing and improving HCBC.The information should be capturedServing Communities with Special NeedsPeople with special needs include nomadic communities, internallydisplaced persons, refugees and the disabled. This serviceapproach is characterized by special arrangements made to reachand serve these hard-to-reach groups. The following are some ofthe possible arrangements:• Training members of the community as community serviceproviders.• Providing satellite or outreach services at designated points foreasy access by the community.• Providing mobile services to either move or reach suchcommunities.• Ensuring services provided are captured through the use ofrelevant data collection tools.Comprehensive Care Package9

and recorded using standardizedtools designed for the collection ofdata on HCBC activities.2.2.2 Quality of ServicesThe minimum HCBC package (seeChapter 3) will form the basis formonitoring the quality of care. Servicequality should include performance ofcare providers according to their skillsand satisfaction, client satisfaction,and family and communityparticipation and empowerment.Emphasis is placed on the principlethat quality is the responsibility ofevery caregiver. Involvement of otherdisciplines and sectors in health careprovision through linkages andnetworking is essential.2.2.3 Supportive SupervisionSupportive supervision is an essentialpart of norms for improving quality ofcare at all levels. Multi-disciplinarysupervisory teams from the DHMT areexpected to ensure that standards ofquality and quantity of care are metduring service delivery. SupervisionQuality of care is theresponsibility of every caregiver.should aim at assessing performanceand promoting good communicationand discussion. The broader aspectof supervision includes appropriatelytrained supervisory teams establishedat national, provincial, district,divisional and location levels.2.3 Operations ResearchThere is need for periodicoperational research on HCBCactivities at all levels of careprovision. Information gathered andanalysed at different care levels willhelp in the identification of bestpractices for replication. The datashould also be used to provideimmediate feedback to HCBCproviders, supervisors and keystakeholders and to facilitatemonitoring of the progress of plannedactivities.10 HOME- AND COMMUNITY-BASED CARE IMPLEMENTATION FRAMEWORK

3 Minimum Package of CareEnsuring that the sick personand the family receivequality care regardless oforganizational constraintsrequires a minimum level of care.Although the comprehensive carepackage described above may seemenormous for implementers withlimited resources or those in theirearly stages of development, theminimum package will guide suchimplementers in the delivery of qualitycare.It is important to – withoutcompromising the quality of caregiven to patients and clients – setpriorities from among the minimumpackage elements to be implemented,and then work towards achieving thefull complement of services beyondthe minimum to the comprehensivepackage. A strong referral andnetworking system is essential toThe minimum HCBC packageincludes:• Nursing and palliative care• Clinical care emphasizingtreatment literacy andsustainability• Family care and support• Capacity building• Linkages, referral andnetworkingMinimum Package of Careensure that all the elements of thecare package are addressed bylinking the patient and family toneeded services.3.1 Elements of the HCBCMinimum PackageBasic human needs form thecore of the minimum HCBCpackage. Among these arehealth care, education and shelter, aswell as social and psychologicalsupport.3.1.1 Nursing Care and PalliativeCareThis aspect of the package includesall basic nursing care, the care of thedying, counselling and psycho-socialsupport, and pain relief. Palliativecare is the combination of active andcompassionate long-term therapiesintended to comfort and supportindividuals and families living with achronic, incurable life-threateningillness.3.1.2 Clinical Care with anEmphasis on TreatmentLiteracy and SustainabilityClient education is the essentialelement here, to ensure adherence tothe prescribed drug regimens for11

ARVs and other drugs foropportunistic infections, as well asother condition medication.Sustainability of the drug supplyensures that the client will not haveunplanned treatment interruption.Clinical care also helps to promotepositive living and prevent infectionand re-infection. Another importantcomponent of care for people livingwith HIV in the community is instillingawareness of the need to seektreatment in case of any ailments nomatter how minor.3.1.3 Family Care and SupportCare services must extend to thefamily in addition to the individualpatient/client and other caregivers.This element includes psychosocialsupport, reproductive health services,nutrition advice and food security forthe family.3.1.4 Capacity BuildingHCBC capacity building targets thevarious cadres at all levels of serviceand care provision. Training for healthcare professionals varies from shortcourses to diploma and degree levelsin HCBC. Once trained, theseprofessionals in turn train others atthe health facility and community levelusing the NASCOP curriculum. Sincelevel 1 (the community) of KEPH isconsidered to have the largestnumber of service providers, bothformal and on-the-job trainingapproaches should be used toaddress knowledge and skill gaps. Acrucial point here is the necessity forquality training by NASCOPaccredited trainers for all levels andcadres of HCBC personnel.3.1.5 Establishing Linkage, Referraland Networking SystemsKnowing where to go for additionalhelp is key to maintaining acomprehensive continuum of care. Acontinuum of care is a system thatinvolves a network of resources andservices that provide holistic andcomprehensive support for the sickperson, family and caregivers. Thegoal is to provide an affordable rangeof services in various settings, fromhome, community and clinics tohospitals, and vice versa. (See alsoSection 4.5.)3.2 Monitoring and Evaluationof the Minimum HCBCPackageAn effective working M&Esystem will have appropriatestructures in place that includeM&E literate staff, a good networkand linkages, and standard reportingprocedures, formats and tools. M&Econstitutes a system for keepingactivities on track towards achievingthe goals of the HCBC programme.M&E should be carried out for allprogrammes implementing HCBC atall levels, from the centre to thecommunity. The results should beshared among partners and the bestpractices replicated amongimplementing programmes. (Refer toChapter 6 for more details.)12 HOME- AND COMMUNITY-BASED CARE IMPLEMENTATION FRAMEWORK

4 HCBC ImplementationStrategiesStrong support strategies arenecessary to strengthen theimplementation of thenational HCBC model aimedat providing a high quality continuumof care. Among the systems that needstrengthening are administration,supervision, monitoring andevaluation, and quality assurance andaccreditation. Others are leadership,coordination, integration of services,logistics and supplies, referral,linkages, and networking at alladministrative and health care levels.Maintaining the optimal number andquality of staff is essential.Concerted action to strengthenthe administrative and health carelevels from the national, regional,provincial, district and division levels,to the community, will ensure a strongand sustainable system that supportsthe individual and affected family. Thislinks directly with the KEPH, whichfocuses on strengthening systemsright from the lowest level of serviceprovision.The following sections summarizeactions needed to strengthen HCBCsystems.4.1 Systems StrengtheningHealth systems consist of allpeople and actions whoseprimary purpose is to promote,restore or maintain health. Thesesystems may be integrated andcentrally directed, or more looselyconnected. They consist of:• Formal health services.• Traditional medicine.• All use of medication whetherprescribed by a provider or not.• Home care of the sick.• Health enhancing interventionslike disease prevention,environmental sanitation, roadsafety.4.1.1 National Level Actions• Develop and review policyguidelines and training curricula.• Facilitate relevant training for staff.• Formulate and review HCBCstrategy.HCBC Implementation Strategies13

• Enhance the capacity of PHMTs tosupervise HCBC activities.• Provide overall direction for HCBCimplementation.4.1.2 Provincial Level Actions• Effectively implement policies,guidelines and strategies.• Facilitate quarterly provincialstakeholder review/consultativemeetings.• Supervise HCBC activities in theprovince.• Provide HCBC training to relevantPHMT members.4.1.3 District and Divisional LevelActions• Coordinate HCBC activities andput monitoring systems in place.• Integrate services and developbest practices in HCBC.• Provide logistics, where possible,for HCBC activities.• Provide HCBC training toimplementers, community healthworkers and care providers.• Facilitate quarterly districtstakeholder review meetings.• Strengthen collaboration andlinkages with other HCBCstakeholders/organizations.• Conduct supportive supervisionfor all HCBC implementingorganizations.4.1.4 Community and Family LevelActions• Provide HCBC training to careproviders in the community andthe household.• Provide logistics for delivery ofHCBC services, e.g., HCBC kits(see Annex C).• Facilitate quarterly stakeholdermeetings.• Facilitate quarterly meetings ofcommunity health workers.• Provide technical support to CBOsinvolved in HCBC.• Establish monitoring, referral andnetworking systems.4.2 Capacity BuildingHealth professionals,volunteers, the sick and familymembers require adequateeducation and training in prevention,treatment and care. In addition,managers at higher levels and seniorstaff at health facilities need to besensitized on home- and communitybasedcare in order to institutionalizeHCBC at all levels in the health caresystem. To strengtheninstitutionalization, health carefacilities need to participate in thetraining activities and supervisepractical attachments to the facilities.The following paragraphs provide abrief guide for the HCBC trainingprogramme.4.2.1 Standardizing the TrainingCurriculum and Length/Duration of TrainingAll HCBC training should beconducted using the nationalcurriculum prepared and approved byNASCOP. Since the curriculum ismodular, training can be phased overa period, but it is not complete until allthe modules have been covered.14 HOME- AND COMMUNITY-BASED CARE IMPLEMENTATION FRAMEWORK

A healthy community iseverybody’s businessCommunity health worker trainingrequires 11 days of classroomsessions combined with a period ofsupervised practical training spreadover two to three months and withperformance reports. Only aftercompletion of both theory andpractical sessions will certification beapproved. The training must becarried out by individuals andinstitutions approved/accredited bythe relevant DHMT. Deferent levels oftraining will be in line with the capacitybuilding objectives described inSection 3.1.4.Additional training content may beidentified to meet the needs ofspecific target audiences, for examplematerials for treatment literacy,adherence to anti-retroviral therapy(ART), stigma reduction, or domestichygiene and sanitation. The KenyaMedical Training College (KMTC), ifadequately prepared, has theinstitutional potential to facilitate theroll-out of HCBC training countrywidein liaison with NASCOP and DHMTs.4.2.2 Identifying/AppointingQualified Trainers/FacilitatorsA high standard of training cannot bemaintained without qualified trainers.Since the key care elements in HCBChave a clinical orientation and involvenursing care, a trainer with a clinicalbackground and relevant trainingskills from an accredited traininginstitution is required.HCBC Implementation Strategies4.2.3 Harmonizing Training Venuesand Monitoring of TrainingsTraining venues will be establishedand approved by the relevant DHMT.Different venues are suitable fordifferent groups of trainees.Assessing learning needs anddetermining the training content forthe various levels will ensure thatsessions are relevant andappropriate. On-site training has beenfound to be most effective in HCBCactivities and notable in cutting costs,hence facilitating larger numbers tobe covered through training.4.2.4 Formalizing Certification ofTraineesA systematic serialization of all HCBCcertificates awarded to successfullytrained health professionals andcommunity health workers ismandatory. This will ensure thatcertification is limited to individualsand cadres who are properly trainedusing the approved curriculum andtraining materials. DHMTs in alldistricts in the country, in collaborationwith NASCOP, are currentlyimplementing this requirement toensure identification of authenticqualifications.4.3 Financing and EnsuringSustainabilitySustainable financial support forHCBC is very challenging forcommunities. Theseprogrammes are often vulnerable toinconsistent and sporadic sources offunding. The following strategies can15

materials. Sharing resources withother health-related NGOs, CBOs,FBOs and community health facilitiescan help to reduce HCBC programmeoperational costs and burden of care.Joint development of resources likeIEC materials can also contribute toconsistency and quality control.4.3.4 Mobilizing CommunityResourceshelp to promote the sustainability ofthe HCBC programme.4.3.1 Preparing Annual OperationalPlansPreparing, managing and reporting onthe HCBC budget for the fiscal yearwill focus attention and reflection onthe district priorities and thereforefacilitate sourcing of funds forrecurrent expenditures.4.3.2 Promoting Public–PrivateSector Partnerships (PPP)In many instances, HCBCprogrammes come about throughpartnership and joint sponsorship ofthe programme. The Government,NGOs, CBOs and the private sectorcan join forces in the “public–privatesector partnership” initiative to help insupporting HCBC activities.4.3.3 Pooling ResourcesAll HCBC programmes require arange of resources such as supplies,equipment, and information,education and communication (IEC)Community leaders, spiritual leadersand political leaders within thecommunity can facilitate themobilization of community resourcesfor care. Resources can also bemobilized to support/sustain HCBCactivities through income-generatingactivities such as community gardens,granaries and farms, craft markets,community fairs, and recreational,sport and artistic events, as well ascontributions from local businessesand FBOs.4.4 Encouraging VolunteerismHCBC can not be sustainedwithout the enormouscontribution of volunteers.Volunteers have one thing in common– a desire and ability to help others.Many volunteers respond to a call forhelp through their places of worship.Others offer to help when they seehow HCBC volunteers have helpedtheir own family, neighbours orfriends. Retention and encouragementof volunteers may be achievedthrough group support activities,training opportunities, honouringvolunteers, and providing awards,honoraria and payment in kind.16 HOME- AND COMMUNITY-BASED CARE IMPLEMENTATION FRAMEWORK

4.5 Linkages, Referral Systemand NetworkingThe primary intention of HCBC isto provide a continuum ofholistic care that is supportedby strengthening referral linkages,follow up, monitoring and casemanagement. The following actionsprovide a guide for maintaining thecontinuum of care.4.5.1 Integrating ServicesThis refers to the mix of care,treatment, psycho-social support andpreventive services in proportions thatmaintain a continuum of care. Thecontinuum involves an integratednetwork of resources and services toprovide holistic, comprehensivesupport for the sick person, the familyand caregivers from home,community, hospitals and vice versa.4.5.2 Strengthening Linkages andNetworkingLinkage is networking with importantservice contributors to the HCBCprogramme. It can be with businesspeople, NGOs, FBOs and otherresource people at the local level.Such relationships should bestrengthened through sharedactivities of staff, service provision,training, monitoring and supervision,and a two-way referral and follow upsystem.Community network meetingsamong the different practitioners,organizations and agencies involvedin caring for the sick and families athome are important. NetworkingHCBC Implementation Strategiesfacilitates discussions on differentissues and possible solutions toproblems such as transport andaccess to certain services.Coordinating committees andlocal leaders, especially the chief whois responsible for resolving localconflicts and problems at communitylevel, should be involved instrengthening community levelnetworking.4.5.3 Establishing Referral SystemsNot all programmes are able to meetall care needs of the patient, familymembers and caregivers. Establishingreferral systems is important foraccess to care services such ashospice care, or caregivers’ access tocounselling and rehabilitationservices. In addition, access tosupport groups, voluntary counsellingand testing, ART and laboratoryservices, spiritual support andguidance services, and other forms ofcommunity-based care may also beneeded. Effective referrals should bemade from health facilities to thehome and back again, highlightingtreatment and care plans to beimplemented. A well organizeddischarge plan ensures a strongreferral system and maintenance ofthe continuum of care.Orphans will need access to childsupport services through theChildren’s Department of the Ministryof Home Affairs, education facilities,child protection programmes andlegal services. Accessing these formsof support require strengtheninglinkages and referral systems.17

4.5.4 Handling Logistics andSuppliesThis system will need to bestrengthened to ensure a reliablesupply of home care kits developedlocally under the guidance of thenational standard content list (seeAnnex C). The standard list (revisedin 2006) provides the minimum type/number of supplies that should be inthe kit and which a community healthworker can use comfortably in thecommunity, without clearance of theMOH especially drugs. Additionalitems may be added depending onlocal needs, but with the supervisionof the professional health worker.4.5.5 Ensuring Food Security,Supplements and Food forPrescriptionMeasures have to be taken to providesupplements, prescription foods andemergency food supplies in the shortterm. Long-term measures must beput in place to ensure food securitythat is sustainable and appropriate.4.6 Quality Assurance andQuality ControlThe HCBC Programme andService Guidelines and theNational HCBC Policy Guideset standards and regulations thatgovern HCBC implementation. ThisHCBC implementation frameworkfurther emphasizes the need forquality in the provision of care. Inorder to discourage “briefcase” HCBCorganizations and to uphold highstandards, DHMTs will accredit HCBCimplementers in their districts. This willbe based on the requirements forquality training, the use of skilledworkers – whether volunteer or paid– and implementation of the approvedminimum care package. The DHMT,through the HCBC supervisors orcoordinators, will be responsible forensuring that these policies,standards and regulations are upheld.4.7 Supervision andCoordinationQuality of care requires that theindividual involved besupervised effectively. It alsodemands the proper supervision andcoordination of the various agenciesand organizations involved in HCBC.4.7.1 Supportive SupervisionAll levels from national (central) toprovince and district will ensure thatpolicy guidelines, administrativearrangements and overallmanagement frameworks publishedby the Government are adhered to.Such supervision is facilitated throughface-to-face forums and establishmentof effective communicationamong all levels of administration andwithin different government agencies.There is need to share reports ofsupportive supervision with othercollaborating HCBC implementers.4.7.2 CoordinationThe Government through NASCOPand the National AIDS ControlCouncil (NACC) has set upcoordinating committees at all18 HOME- AND COMMUNITY-BASED CARE IMPLEMENTATION FRAMEWORK

administrative levels, the lowest ofwhich is the ConstituencyCoordinating Committee. Closesupervision by DHMTs, and thePHMT’s coordination of HCBCactivities within various districts,should be achieved. Any organizationimplementing HCBC activities mustmake its activities known to theseteams right from the planning stagethrough all the implementation,monitoring and evaluation phases.The DHMT should keep an inventoryof all organizations undertakingHCBC activities in each district with agoal of strengthening stakeholderparticipation.4.7.3 HCBC OrganogramThe various players in HCBC, fromMOH to the communities, are shownin Figure 1.Figure 1:Players, stakeholders and relationships in HCBCMinistry of HealthNational AIDS/STDControl Programme(NASCOP)‡ˆPHMTPASCOPHCBCC‡ˆDHMTDASCODHCBCCDivisional HCBCC‡‡ˆ‡ˆCHEWs‡†… †… †… ††… †National AIDSControl Council(NACC)‡ˆRegional HIV/AIDSfocal personˆDistrict TechnicalCommitteesˆConstituency AIDSControl CommitteeˆCommunity health workers, volunteersˆClients, patients, families, households and communities‡‡‡‡……… †ˆ… ††OtherAIDS ControlUnits†‡Civil society:NGOs/CBOs‡‡HCBC Implementation Strategies19

5 National HCBCImplementation StepsThe Ministry of Health’sCommunity Strategy for thedelivery of level 1 serviceshas as one of its mainobjectives the strengthening of healthfacility-community linkage through theeffective decentralization andpartnership. It is through thestipulated community structures thatHCBC will be implemented. Thisstructure emphasizes the focus oncatchment areas within a specific sublocation.Each area serves 5,000people through 50 community healthworkers (CHWs) and 2 supervisors(Community Health ExtensionWorkers – CHEWs). Each supervisorsupervises 25 CHWs and each CHWis expected to serve 20 households(approximately 100 people). All HCBCimplementers should therefore workclosely with the relevant DHMTs andPHMTs in identifying priority areas toensure equity in service delivery.Steps in implementing such aprogramme include assessing needs,planning and organizing theprogramme, actual implementation,and comprehensive monitoring andevaluation. The steps are itemizedbelow.5.1 Assessment5.1.1 Situation Analysis• Delineate geographical catchmentarea.• Define the target population, theirdemographic data and their careneeds.5.1.2 Logistic Analysis• Consider availability of theworkforce including training gaps.• Assess other available resourcesincluding HCBC kits and funds.5.1.3 Networking, Referral andLinkage• Identify other organizationsserving this population andservices they offer.20 HOME- AND COMMUNITY-BASED CARE IMPLEMENTATION FRAMEWORK

• Determine the availability ofresources/services for possiblereferral of clients to ensurecomprehensive care provision.5.2 Planning and Organizing• Ensure adequate personneltrained in HCBC, e.g., CHWs,supervisors and coordinators.• Formulate both short-term andlong-term budgetary andworkplans for sustainability.• Ensure appropriate planning forlogistics to last at least two years.• Plan to offer quality care coveringat least three components of theminimum HCBC package and astrong referral for other careservices.• Identify care networks to link andrefer for components not directlyoffered using standard referraltools.• Be familiar with and make use ofHCBC documents from theMinistry of Health, NASCOP andNACC that guide the provision ofquality care at home andcommunity level. (Refer to AnnexB for a selection for relevantdocuments.)• Plan for the motivation,appreciation and sustainability ofCHW caregivers.5.3 Implementation• Seek acceptance and ownershipby community-owned resourcepersons (CORPs), e.g., leaders.• Provide services as plannedensuring quality care and linkagewith health care systems.5.4 Monitoring and Evaluation• Conduct continuous monitoring ofplanned activities, midterm andend term evaluation ofprogramme activities.• Use standard tools for datacollection and reporting, such asCHW diaries, CBO registers, form726 annex and others.• Carry out organizational dataanalysis for use in improving weakareas and supporting strong areasfor continuity.National HCBC Implementation Steps21

6 Monitoring and EvaluationMonitoring and evaluation(M&E) is an essentialcomponent of anyprogramme that isimplementing an HCBC programme.The purpose of M&E is to keepactivities on track towards programmegoals. An effective M&E systemcomprises appropriate structures thatinclude M&E trained staff, goodreporting procedures andappropriately detailed reporting tools.6.1 Importance of M&EAll programmes implementingHCBC at all levels, from thecentre to the community,should have an effective monitoringand evaluation system in place, andshould ensure that it is used. Theresults should be shared with partnersand best practices replicatedappropriately.Community health workers shouldbe guided on how to report theactivities they carry out in thecommunity and their specificcatchment areas to minimize cases ofreporting overlap and duplication ofreports. Information collected at thislevel is very important because itconstitutes the basic data that informthe programme at higher levels andfor future planning of activities.6.2 Link between MOH andNACC M&E SystemProper linkages of home- andcommunity-based careprogrammes and health facilityinformation systems must be in place.There must be a focal point at thehealth facility to link the facility withthe CHW or CBO. The focal point canbe an office or desk with a list of allCHWs, all CBOs involved in HCBC,an HCBC client register and contactsfor care providers.It is through the focal point thatdata collected in the community willbe channelled upward. At divisionallevel, the divisional home andcommunity care coordinator willcompile data for onward flow to thedistrict level. The coordinator will alsoanalyse and interpret the data forlocal consumption and work closelywith the Constituency AIDS ControlCommittee.The District Home- andCommunity-Based Care Coordinator(DHCBCC), with the supervision ofthe District AIDS/STD ControlCoordinator (DASCO), will compilethe district data for onward flow to theprovince and analyse and interpret itfor consumption at district level. Theprovincial HCBC Coordinator, with thesupervision of the PASCO, will22 HOME- AND COMMUNITY-BASED CARE IMPLEMENTATION FRAMEWORK

compile data for onward flow toNASCOP and will work closely withthe NACC regional representative toanalyse and interpret the data forregional use. At national level,NASCOP and NACC will compile,analyse, interpret and disseminatedata to support planning and to informnational and international partnersappropriately through regular forumsand publications. There should, infact, be regular forums at every levelto inform every player of any changesmade in the monitoring andevaluation system.6.3 ToolsThe reporting tools used at everylevel of implementation shouldbe the same nationally, i.e.,CHW diary, CBO register, MOH formsand NACC’s community-basedprogramme activity reporting(COPAR) form. These tools are to beprepared (or modified) withconsultation or support from otherpartners though NASCOP and NACC,and then distributed to allimplementers.Monitoring and Evaluation23

Annex A: ContributingStakeholder Organizations1. National AIDS Control Council(NACC)2. Ministry of Health• Department of SectorPlanning and Management• National AIDS/STD ControlProgramme (NASCOP)• Division of Nursing• Division of Health Promotion• Nyanza Province, North RiftValley Province, CoastProvince• Siaya District, Kisumu District,Nakuru District, Mwingi District3. Pathfinder International4. St. John Ambulance5. Family Health International6. Johns Hopkins Program forInternational Education inGynaecology and Obstetrics(JHPIEGO)7. Women Fighting AIDS in Kenya(WOFAK)8. Network of People with HIV/AIDSin Kenya (NEPHAK)9. Kenya Women with AIDS(KENWA)10. WEM Integrated Health Services(WEHMIS)11. Kenya Medical Training College(KMTC)12. Kenya Red Cross Society (KRCS)13. Mildmay International14. Kenyatta National Hospital VCTcentre15. Kenya AIDS NGOs Consortium(KANCO)16. Catholic Diocese of Kitui Home-Based Care Project17. Catholic Diocese of NakuruHome-Based Care Project18. Maua Methodist Church Palliativeand Community-Based CareProject19. Anglican Church of Kenya (ACK)Diocese of Eldoret HIV CareProject20. Karatina Home-Based CareProject21. Health Policy Initiative24 HOME- AND COMMUNITY-BASED CARE IMPLEMENTATION FRAMEWORK

Annex B:Additional Reading1. National Strategy to StrengthenHome-Based Care Access,Sustainability and Quality inKenya 2005–2009, NASCOP,20042. National Home-Based Care PolicyGuidelines, NASCOP, 20023. National Home-Based CareProgramme and ServiceGuidelines, NASCOP, 20014. Training Home-Based Caregiversto Care for People Living with HIV/AIDS at Home – A Curriculum forTraining Community HealthWorkers, Second Edition,NASCOP, 20065. Home Care Handbook, SecondEdition, NASCOP, 20066. Monitoring and evaluation tools:MOH form 726/7, COPAR, CBOregister, CHW diary7. National Voluntary Counsellingand Testing Guidelines, MOH/NASCOP, 20018. Training Curriculum for VoluntaryCounselling and Testing, MOH/NASCOP, 20039. National Guidelines on Preventionof Mother to Child Transmission ofHIV, Second Edition, MOH/NASCOP, 200210. National Policy Guidelines on theUse of Anti-Retroviral drugs, ThirdEdition, MOH/NASCOP, 200511. National Condom Policy andStrategy 2001–2005, MOH andNACC, 200112. HIV/AIDS Prevention and ControlAct, No. 14 of 200613. Kenya National HIV/AIDSStrategic Plan, 2005/6 – 2009/10,NACC, June 200514. Kenya National OVC PolicyGuide, Ministry of Home Affairs(MOHA), draft15. Kenya National OVC ProgrammeGuidelines, MOHA, March 200316. The Children Act, cap 586, TheLaws of Kenya, 200117. Kenya National Nutrition in HIVGuidelines, MOH, 200618. National Health Sector StrategicPlan 2005–2010 (NHSSP II),MOH, 200519. Community Reproductive HealthPackage, MOH/DRH, 200620. Taking the Kenya EssentialPackage for Health to theCommunity: A Strategy for theDelivery of LEVEL ONEAnnex B: Additional Reading25

SERVICES (The CommunityStrategy), MOH, 200722. Reversing the Trends: TheSecond National Health SectorStrategic Plan of Kenya – TheKenya Essential Package forHealth (KEPH), MOH, 200723. Key Health Messages for Level 1of the Kenya Essential Packagefor Health – A Manual forCommunity Health ExtensionWorkers and Community HealthWorkers, MOH, 200724. Preparation of Expert PatientTrainers, MOH, April 200725. AIDS control and preventionprojects AIDSCAP, HIVAIDS careand support projects – FamilyHealth International, Project 936-5972.31-469204626 HOME- AND COMMUNITY-BASED CARE IMPLEMENTATION FRAMEWORK

Annex C: Standard MinimumHCBC Kit Content (Revised 2006)Item description Quantity Unit1 Latex gloves 100 Box2 Condoms 1 Box3 Scissors 1 Pair4 Bar soap 3 Pieces5 Paracetamol 60 Tabs6 Multivitamins 30 Tabs7 Clopheniramine (piriton) 30 Tabs8 Gentian violet (GV) paint 1 Bottle9 Chlorine bleach (Jik) 250 mls 2 Bottle10 Waste disposal bags 14 x 9 50 Pieces11 Cotton wool 100 grams 2 Rolls12 Gauze 25 Pieces13 Cotton bandages 6 Rolls14 Oral rehydration salts 20 Sachets15 Vaseline (petroleum gel) 50 grams 2 Bottles16 Zinc oxide plaster 1 x 2.5 1 Rolls17 Antiseptic lotion (Hibitine) 125mls 2 Bottles18 Toilet paper 2 Pieces19 Nutrition kit (e.g., Insta powder) 1 PacketAnnex C: HCBC Kit Contents27

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”-”-”-”-”-”-”--”-”-”-”-”-”-””-”-”-”-”-”-”--”-”-”-”-”-”-””-”-”-”-”-”-”--”-”-”-”-”-”-””-”-”-”-”-”-”--”-”-”-”-”-”-””-”-”-”-”-”-”--”-”-”-”-”-”-””-”-”-”-”-”-”--”-”-”-”-”-”-””-”-”-”-”-”-”--”-”-”-”-”-”-””-”-”-”-”-”-”--”-”-”-”-”-”-””-”-”-”-”-”-”-

An Implementation FrameworkFor Home- and Community-Based Care in KenyaNational AIDS/STD Control ProgrammeMinistry of HealthPO Box 19361- City Square, Nairobi 00200, KenyaTel: 254-20-272-9502/9549 Fax: 254-20-271-0518www.aidskenya.org